Question

J.S. is a 21-year-old male who was brought into the emergency room via ambulance after suffering a gunshot wound to the spine. At the accident scene, the paramedics noted J.S. had some movement of all his fingers and only his left leg. J.S. was not able to move his right foot.

Based upon the above situation:

1. What is the level of injury?
2. Is the cord injury complete or incomplete?
3. What type of lesion is he presenting (central cord, brown-sequard, anterior, conus medullaris, or cauda equina). Support your answer.

J.S.'s parents are present and ask you if he will every gain control of legs and feet.

4. Do you expect J.S. to eventually gain control of his legs and feet?

5. How would you explain primary and secondary injury in terms the parents will understand?
6. Compare and contrast cervical, thoracic, and sacral lesions.

Autonomic dysreflexia is an acute emergency.

7. What is autonomic dysreflexia?
8. What is the cause?
9. What are the manifestations?

Answer 1

1 Ans )

# Introduction

Your ability to control your limbs after a spinal cord injury depends on two factors: the place of the injury along your spinal cord and the severity of injury to the spinal cord.

The lowest normal part of your spinal cord is referred to as the neurological level of your injury. The severity of the injury is often called "the completeness" and is classified as either of the following:

• * Complete. If all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury, your injury is called complete.
• * Incomplete. If you have some motor or sensory function below the affected area, your injury is called incomplete. There are varying degrees of incomplete injury.

Additionally, paralysis from a spinal cord injury may be referred to as:

• * Tetraplegia. Also known as quadriplegia, this means that your arms, hands, trunk, legs and pelvic organs are all affected by your spinal cord injury.
• * Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs

In this case

"At the accident scene, the paramedics noted J.S. had some movement of all his fingers and only his left leg. J.S. was not able to move his right foot."

So this case level is incomplete

2 Ans )

Incomplete. If you have some motor or sensory function below the affected area, your injury is called incomplete. There are varying degrees of incomplete injury.

3ans)

# Introduction

Incomplete spinal cord syndromes are caused by lesions of the ascending or descending spinal tracts that result from trauma, spinal compression, or occlusion of spinal arteries. Central cord syndrome, anterior cord syndrome, posterior cord syndrome, and Brown-Séquard syndrome are the most common types of incomplete spinal cord syndromes. In contrast to a complete spinal cord injury, lesions only affect part of the cord and patients present with a dissociated sensory loss. A spine MRI is the diagnostic modality of choice to determine the etiology, level, and extent of the lesion. Treatment depends on the underlying etiology.

# Anterior cord

Introduction.

Anterior cord syndrome is an incomplete cord syndrome that predominantly affects the anterior 2/3 of the spinal cord, characteristically resulting in motor paralysis below the level of the lesion as well as the loss of pain and temperature at and below the level of the lesion

Many patients with CCS make a spontaneous recovery of motor function, while others experience considerable recovery in the first six weeks after injury. If the underlying cause is edema or swelling in the spinal cord, recovery may occur relatively soon after an initial period of weakness.

So the patient able to move his leg after some time. Recovery is possible

4 ans)

its possible to control his feet and leg

Management of leg movement

Many patients with CCS make a spontaneous recovery of motor function, while others experience considerable recovery in the first six weeks after injury. If the underlying cause is edema or swelling in the spinal cord, recovery may occur relatively soon after an initial period of weakness.

• * Physical therapy uses treatments such as heat, massage, and exercise to stimulate nerves and muscles.
• * Occupational therapy concentrates on ways to perform activities of daily living.
• * Mobility aids include manual and electric wheelchairs and scooters.
• * Supportive devices include braces, canes, and walkers.
• * Assistive technology such as voice-activated computers, lighting systems, and telephones.
• * Adaptive equipment such as special eating utensils and controls for driving a car.

5 ans)

Spinal cord injuries may be primary or secondary. Primary spinal cord injuries arise from mechanical disruption, transection, or distraction of neural elements. This injury usually occurs with fracture and/or dislocation of the spine. However, primary spinal cord injury may occur in the absence of spinal fracture or dislocation. Penetrating injuries due to bullets or weapons may also cause primary spinal cord injury. More commonly, displaced bony fragments cause penetrating spinal cord and/or segmental spinal nerve injuries.

It’s this initial structural and cellular damage that triggers the secondary injury cascade. As the name suggests, the secondary injury cascade is a series of changes—often developing one after the other—that begin within just a few hours after the SCI and may continue more than 6 months past the initial injury.

6 ans)

# introduction

For the cervical cord, lesions were more frequently lateral (51.4%) and posterior (19.3%), whereas thoracic cord lesions were more frequently patchy (32.5%) or lateral (39.8%). Spinal cord lesion distribution by the level involved.

# cervical lesions

Lesion is a general term for tissue that has been injured, destroyed, or otherwise has a problem. Spinal lesions affect the nervous tissue of the spine. They may be due to: Cancerous or non-cancerous tumors. Trauma.

# Thoracic lesions

Unfortunately, because thoracic spinal lesions are rare, they can often be misdiagnosed at first . Extradural spinal lesions such as calcified, herniated disks in the thoracic spine most commonly present as localized pain in the uper back or pain along a dermatomal distribution in the chest or abdominal area .

# Sacral lesion

Because the sacrum has an architecture similar to that of the rest of the spine, mass lesions may involve primarily the bone structure or the sacral canal. A variety of benign and malignant neoplasms occur in the sacrum.Metastatic lesions of the sacrum are far more common than primary malignancy

7 ans)

= Introduction.

Autonomic dysreflexia is a condition that emerges after a spinal cord injury, usually when the injury has occurred above the T6 level. The higher the level of the spinal cord injury, the greater the risk with up to 90% of patients with cervical spinal or high-thoracic spinal cord injury being susceptible

# Definition

Autonomic dysreflexia (AD) is a condition in which your involuntary nervous system overreacts to external or bodily stimuli. It’s also known as autonomic hyperreflexia. This reaction causes:

• *a dangerous spike in blood pressure
• * slow heartbeat
• * constriction of your peripheral blood vessels
• * other changes in your body’s autonomic functions

# How autonomic dysreflexia happens in the body

To understand AD, it’s helpful to understand the autonomic nervous system (ANS). The ANS is the part of the nervous system responsible for maintaining involuntary bodily functions, such as:

• * blood pressure
• * heart and breathing rates
• * body temperature
• * digestion
• * metabolism
• * balance of water and electrolytes
• * production of body fluids
• * urination
• * defecation
• * sexual response

There are two branches of ANS:

• * sympathetic autonomic nervous system (SANS)
• * parasympathetic autonomic nervous system (PANS)

8 ans)

# Causes of AD

Autonomic dysreflexia is caused by an irritant below the level of injury, including:

• * Bladder: irritation of the bladder wall, urinary tract infection, blocked catheter or overfilled collection bag.
• * Bowel: distended or irritated bowel, constipation or impaction, hemorrhoids or anal infections.
• * Other causes include skin infection or irritation, cuts, bruises, abrasions or pressure sores (decubitus ulcers), ingrown toenails, burns (including sunburn and burns from hot water) and tight or restrictive clothing.

AD can also be triggered by sexual activity, menstrual cramps, labor and delivery, ovarian cysts, abdominal conditions (gastric ulcer, colitis, peritonitis) or bone fractures.

9ans)

The manifestations are variable and include:

• * A severe headache
• * Profuse diaphoresis above the level of injury
• * Flushing above the level of injury
• * Piloerection above the level of injury
• * Dry and pale skin because of vasoconstriction below the level of injury
• * Visual disturbances
• * Nasal stuffiness
• * Anxiety or feelings of doom
• * Nausea and vomiting

Hypertension may be asymptomatic or be severe enough to lead to a hypertensive crisis complicated by pulmonary edema, left ventricular dysfunction, retinal detachment, intracranial hemorrhage, seizures or even death. Bradycardia may also range from minor to resulting in cardiac arrest. Tachycardia is less common than bradycardia but may also occur along with cardiac arrhythmias and atrial fibrillation or flutter. If the patient has coronary artery disease, an episode may cause a myocardial infarction.

The combination of dangerously high blood pressure together with cerebral vasodilation puts the patient at high risk for a hemorrhagic stroke which can be life-threatening.

# Autonomic Dysreflexia Diagnosis

Your doctor will measure your blood pressure while they figure out what triggered your autonomic dysreflexia episode. They’ll check your bladder and bowels, since fullness or a blockage there is usually the cause of the problem.

You may need imaging tests, like X-rays or an ultrasound, or lab tests on your blood or urine.

# Autonomic Dysreflexia Treatments

If you have autonomic dysreflexia symptoms, here are a few things you can do until you can get medical help:

• * Sit up as much you can. This helps move more blood to your lower body and ease your blood pressure
• * Take off tight clothes or other irritants
• * Pee
• * Quick steps can keep the problem from getting worse. Your doctor may give you medication to make your blood pressure drop quickly. If the problem is severe, they may watch your blood pressure for 2-48 hour
• # Autonomic Dysreflexia Prevention

• You can take steps to lower your chance of complications:

• * Use the bathroom on a regular schedule. Keep your bladder and bowels from becoming too full.
• * Know the signs of a bladder infection.
• * Take care not to get skin sores or ingrown toenails.
• * Carry a card for emergencies to let people know you might have autonomic dysreflexia.

• # Autonomic Dysreflexia Complications

  Autonomic dysreflexia can be a life-threatening condition. It can cause bleeding in the brain, stroke, seizures, and other heart and lung